Carlos Augusto Scussel Madalosso

The Impact of Gastric Bypass on Gastroesophageal Reflux Disease in Patients With Morbid Obesity: A Prospective Study Based on the Montreal Consensus

Objectives:To assess the impact of gastric bypass (GBP) on gastroesophageal reflux disease (GERD) based on Montreal Consensus. Methods:In this study, 86 patients (25 men; aging 38 ± 12 years; body mass index 45 [35–68 kg/m2]) were investigated for GERD before GBP and 6 months later. Esophageal and extraesophageal syndromes were assessed based on Montreal Consensus. Esophageal acid exposure and gastric pouch acidity were also evaluated. Results:Overall prevalence of GERD was 64% before GBP and 33% after GBP (P < 0.0001). Typical reflux syndrome (TRS) was present in 47 patients (55%) preoperatively and disappeared in 39 of them (79%) post-GBP. Out of 39 patients with no symptoms, 4 (10%) developed TRS postoperatively (P < 0.0001). The chief TRS complaint changed from heartburn pre-GBP (96%) to regurgitation post-GBP (64%). Esophageal mucosa improved in 27, was unchanged in 51, and worsened in 8 patients (P = 0.001) in regard of esophagitis. Extraesophageal syndromes were present in 16 patients preoperatively and in none but one post-GBP (P = 0.0003). GERD-related well being and use of proton pump inhibitors were both improved after GBP. Total acid exposure decreased from a median (interquartile range, 25%–75%) of 5.1% (range, 2–8.2) to 1.1% (range, 0.2–4.8), P = 0.0002. Most patients (86%) showed and acid gastric pouch in fasting conditions post-GBP. Conclusions:GBP ameliorated GERD syndromes in most patients 6 months after the procedure, resulting in quality of life improvement and less proton pump inhibitors usage. Whether regurgitation post-GBP corresponds to reflux disease or bad eating behavior deserves further studies.

The role of gastro-oesophageal pressure gradient and sliding hiatal hernia on pathological gastro-oesophageal reflux in severely obese patients

Background and aims The relationship between gastro-oesophageal pressure gradient (GOPG), sliding hiatal hernia (SHH) and gastro-oesophageal reflux disease (GORD) is under investigation. We assessed whether GOPG and SHH are predictors of pathological reflux in severely obese patients. Methods Ninety-four consecutive patients were prospectively studied with oesophageal manometry, 24-h pH monitoring, upper gastrointestinal endoscopy and barium swallow X-ray. Inspiratory and expiratory GOPGs were measured at manometry testing, whereas SHH was characterized by X-ray. Patients were classified as having physiological or pathological reflux depending on pH monitoring. Patients with oesophagitis but normal pH testing were excluded. Results Eighty-nine patients composed the study sample (25 men, 38.3±11.1 years; BMI 45±6.9 kg/m2). Sixty-two patients (70%) had pathological reflux, whereas 27 patients (30%) had physiological reflux. Pathological reflux was predicted either by inspiratory GOPG [prevalence ratio (PR) =1.05; 95% confidence interval (CI): 1.03–1.08; P<0.001] or by expiratory GOPG (PR=1.07; 95% CI: 1.03–1.11; P=0.001). Accordingly, an increment of 1 mmHg in inspiratory and expiratory GOPGs raises the risk of pathological reflux in 5 and 7%, respectively. Pathological reflux was also predicted by SHH (PR: 1.54, 95% CI: 1.19–2.00; P=0.001), which increases the risk of abnormal reflux in 54%. Conclusion In severely obese patients, either inspiratory GOPG, expiratory GOPG or SHH are predictors of pathological reflux. These findings give pathophysiological support to the high prevalence of GORD in this population.

Performance of the Montreal Consensus in the Diagnosis of Gastroesophageal Reflux Disease in Morbidly Obese Patients

BackgroundGastroesophageal reflux disease (GERD) has been increasingly recognized in patients with morbid obesity. A recent global evidence-based consensus on GERD has been proposed, but its performance in patients with morbid obesity is unknown. The aim of this study was to assess the performance of the Montreal Consensus in the diagnosis of GERD in morbidly obese patients.MethodsSeventy-five consecutive morbidly obese patients underwent GERD symptoms assessment, upper gastrointestinal endoscopy, and ambulatory esophageal pH monitoring “off PPI”. The performance of the Montreal Consensus was determined by comparing two diagnostic algorithms: 1. a gold standard approach in which any GERD symptom and findings from both endoscopy and pH monitoring were taken into account, and 2. the approach with the Montreal Consensus, in which troublesome GERD symptoms and endoscopic findings were considered.ResultsGERD was found present in 57 patients by applying the gold standard approach. The Montreal Consensus identified 41 of these patients, whereas the remaining 34 patients were classified as “no GERD”. Of these, 16 (47%) showed reflux esophagitis and/or abnormal pH-metry. The Montreal Consensus had an accuracy of 78.7%, sensitivity of 72% (95% CI 59–82%), specificity of 100% (95% CI 82–100%) and negative predictive value of 47% (95% CI 37–57%).ConclusionsIn morbidly obese patients, the approach with the Montreal Consensus has high specificity and suboptimal sensitivity in the diagnosis of GERD. Its intermediate negative predictive value suggests that complementary investigation might be routine in these patients, particularly in those who do not present with troublesome GERD symptoms.

Heartburn during sleep: a clinical marker of gastro-oesophageal reflux disease in morbidly obese patients.

Abstract  Gastro‐oesophageal reflux disease (GORD) and morbid obesity are entities with increasing prevalence. New clinical strategies are cornerstones for their management. The aim of this study was to assess the prevalence of heartburn during sleep (HDS) and whether this symptom predicts the presence of objective GORD parameters and increased heartburn perception in morbidly obese patients. Ninety‐one consecutive morbidly obese patients underwent clinical evaluation, upper gastrointestinal endoscopy and oesophageal pH monitoring. HDS was characterized when patients replied positively to the question, ‘Does heartburn wake you from sleep?’. A General Score for Heartburn (GSH) ranging between 0 and 5 was assessed with the question ‘How bad is your heartburn?’. HDS was reported by 33 patients (36%). More patients with HDS had abnormal acid contact time or reflux oesophagitis than patients without HDS (94%vs 57%, P < 0.001). HDS had a positive predictive value of 94% (0.95 CI 82–98), sensitivity of 48% (0.95 CI 37–60%) and specificity of 93% (0.95 CI 77–98%) for detection of GORD. A higher proportion of patients with HDS perceived heartburn preceded by acid reflux in diurnal (39%vs 9%; P < 0.001) periods during pH‐metry. HDS patients showed higher GSH (2.4 ± 0.5 vs 1.7 ± 0.4; P < 0.0001) compared with patients who denied HDS but reported diurnal heartburn. HDS occurs in a significant minority of patients with morbid obesity and has high positive predictive value for GORD. Symptomatic reflux during the sleep seems to be a marker of increased heartburn perception in this population.

Epidermal Growth Factor Receptor Expression in Esophageal Adenocarcinoma: Relationship with Tumor Stage and Survival after Esophagectomy

Background and Aims. Esophageal adenocarcinoma (EA) is an aggressive tumor with increasing incidence in occidental countries. Several prognostic biomarkers have been proposed, including epidermal growth factor receptor (EGFR). The aim of this study was to assess whether EGFR expression predicts EA staging and patient survival. Methods. In this historical cohort, consecutive patients with EA managed between 2000 and 2010 were considered eligible for the study. Surgical specimens of patients treated with transhiatal esophagectomy were evaluated to establish EGFR expression and tumor differentiation. Staging was classified according with tumor-node-metastasis (TNM) system. Survival was determined according to either medical register or patients family contact. Results. Thirty-seven patients who underwent esophagectomy without presurgical chemotherapy or radiotherapy were studied. EGFR expression was found in 16 patients (43%). EGFR expression was more frequent as higher was the TNM (I and II = 0% versus III = 47% versus IV = 100%; P < 0.001). Average survival in months was significantly shorter in the group of patients with EGFR expression (10.5 versus 21.7; P = 0.001). Conclusions. In patients with esophageal adenocarcinoma treated with transhiatal esophagectomy, EGFR expression was related to higher TNM staging and shorter survival. EGFR expression might be assumed as a prognostic marker for esophageal adenocarcinoma.

Incarcerated right-sided diaphragmatic hernia in a patient undergoing Roux-en-Y gastric bypass

Bochdalek hernia is the most common congenital diaphragmatic hernia. Its symptoms are normally diagnosed and treated during the neonatal period. Conversely, in adults it is usually asymptomatic and, as a consequence, this group is misdiagnosed. A case of a 64-year-old female patient with an uncommon incarcerated right-sided diaphragmatic hernia formed three years after a Roux-en-Y gastric bypass and a significant weight loss is reported. The importance of this abnormality as a complication of the bariatric surgery should be considered. Key words: Diaphragmatic hernia; gastric bypass; bariatric surgery.

Mirizzi Syndrome Type IV: A challenging diagnosis

Mirizzi Syndrome type IV is an extremely rare condition, which is confused with the diagnosis of cholangiocarcinoma in many cases. This report describes a case of a forty-three-year old patient, who was forwarded to our department of general surgery with a high suspicion of a choledochal neoplasic lesion. During the hospitalization he was diagnosed with Mirizzi Syndrome type IV. We concisely describe the case and the literature review about this pathology.